Published on K4Health (https://www.k4health.org)

Postpartum Hemorrhage: Prevention and Management Toolkit

To assist country programs, donors and governments to develop comprehensive and innovative programs to address public health priorities?such as hemorrhage, the leading cause of maternal mortality worldwide?this program guidance document outlines key steps, identifies available resources, and highlights lessons learned from current projects.

This Postpartum Hemorrhage: Prevention and Management

toolkit was developed by the USAID-funded Maternal and Child Health Integrated Program (MCHIP) as a resource of current evidence, materials and experiences from around the world. It reflects contributions from many donors, agencies, associations, academic institutions and organizations which have identified postpartum hemorrhage as a priority?and contribute in different ways to addressing it. It links to the existing POPPHI postpartum hemorrhage toolkitwhich houses numerous resources, articles and materials.

The purpose of this and other MCHIP toolkits is to collect and package resources that are useful to country programs for developing, implementing, monitoring and scaling up maternal health related interventions at various levels. MCHIP has created a number of useful resources for this toolkit including a PPH program implementation guide.

In 2013, a new section focused on advance distribution of misoprostol for PPH prevention has been created in this toolkit. Because of a broadening interest in reducing postpartum hemorrhage-related mortality and morbidity, it is expected that this toolkit will grow significantly in the coming years as country-level programs design, implement and evaluate PPH-related interventions.

Useful Websites, Online Courses and Resources

The Maternal and Child Health Integrated Program (MCHIP) is the USAID Bureau for Global Health?s flagship maternal, neonatal and child health (MNCH) program. MCHIP supports programming in maternal, newborn and child health, immunization, family planning, malaria and HIV/AIDS, and strongly encourages opportunities for integration. Cross-cutting technical areas include water, sanitation, hygiene, urban health and health systems strengthening. Visit www.mchip.net for more information.

 

                         

What is the purpose of this toolkit?

The purpose of this and other MCHIP toolkits is to collect and package resources that are useful to country programs for developing, implementing, monitoring and scaling up maternal health related interventions at various levels. MCHIP has created a number of useful resources for this toolkit including a program implementation guide.

Who developed this toolkit?

This toolkit was developed by the USAID-funded Maternal and Child Health Integrated Program (MCHIP). MCHIP supports programming in maternal, newborn and child health, immunization, family planning, malaria and HIV/AIDS, and strongly encourages opportunities for integration.

What types of resources are included?

This toolkit contains current evidence, materials and experiences from around the world. It reflects contributions from many donors, agencies, associations, academic institutions and organizations which have identified postpartum hemorrhage as a priority?and contribute in different ways to addressing it.

Who are the intended audiences?

This toolkit is intended for country programs to develop, implement, monitor and scale up maternal health related interventions at various levels.

Related eLearning Courses: Preventing Postpartum Hemorrhage

Step 1: Advocate with EvidencePreventing tragic maternal deaths due to postpartum hemorrhage (PPH) begins with gaining stakeholders? buy-in. It is often necessary to advocate for these lifesaving interventions to be introduced into the national public health system.

Demonstrate that PPH is a public health priority:

? Hemorrhage is a leading direct cause of maternal deaths in the world. 14 million women in developing countries experience PPH?26 women every minute.1

? PPH is preventable through use of simple interventions that should be offered to all women at the time of birth.

? PPH is treatable, but requires rapid recognition and care to prevent life-threatening consequences; a woman can die from PPH in just two hours.

? PPH is unpredictable; therefore, every pregnant woman needs care during childbirth from a skilled birth attendant (SBA).2 However, in developing countries, almost 50% of deliveries occur at home without an SBA.3 Women giving birth without an SBA are at increased risk of dying from complications including PPH.

Promote evidence-based interventions for PPH prevention and management:

? PPH prevention can reduce PPH-related deaths through: active management of the third stage of labor (AMTSL) by an SBA; and birth preparedness and complication readiness counseling, PPH prevention counseling, and antenatal provision of misoprostol for use at the time of birth when delivery with an SBA is not possible.

? PPH management can further reduce PPH-related deaths through: a number of interventions mainly available within facilities with skilled providers; and basic or comprehensive emergency obstetric and newborn care (BEmONC or CEmONC) services.

Provide evidence to key stakeholders and decision-makersto assist in shaping policy. This can be done by:

? Organizing information sessions that provide the evidence base for recommended PPH prevention and treatment interventions.

? Conducting a series of technical updates presenting data on: maternal mortality ratio (MMR); country- or region-specific PPH prevalence and rates of skilled attendance at birth; global evidence on PPH prevention and management; and results from PPH prevention and management research and projects.

? Conducting surveys that study existing practices, policies and training curricula to understand where the country is in terms of PPH prevention and/or treatment.

? Designing research to help policymakers, program managers and health service administrators understand factors that inhibit access to adequate, affordable interventions for PPH preventions and treatment, especially for vulnerable populations.

? Identifying innovative interventions and approaches that can be tested and evaluated to demonstrate safety and program feasibility in their context such as: oxytocin in the Uniject® device; reducing misoprostol dosage; introducing the non-pneumatic anti-shock garment; and mainstreaming the use of the condom tamponade. Governments should choose a strategic approach that suits their situation, such as beginning with a demonstration project or pilot.

Develop champions for PPH prevention: To ensure that PPH is on the national agenda, it is helpful to have champions at the national level who are convinced of the evidence and can persuasively advocate to decision makers for PPH interventions. Key government officials, members of professional associations, pre-service and in-service educational programs, and influential clinicians can all be powerful champions.

Discuss with government counterparts, global agencies, donors, educational institutions, professional associations, local nongovernmental organizations, and maternal health stakeholders to generate support. It is important to build commitment among technical leaders at the national level before beginning programming, keeping in mind that some partners remain focused on certain programmatic approaches, and that the evidence base continues to evolve. In many countries, a national PPH Technical Advisory Group (TAG) was created through which stakeholders from the Ministry of Health and implementing partners could guide the program process.

Program Pitfalls and Lessons Learned: Advocacy

? Champions at the national level are essential for introducing new policy for PPH prevention and treatment.

? PPH interventions should be promoted at the national and local level as part of an overall safe motherhood campaign. They should be seen as complementary to an ongoing program to expand skilled attendance and ensure the availability of CEmONC.

? Interventions should be designed to expand coverage of a uterotonic for all births and include efforts to reach vulnerable and marginalized populations.

? Commitment at the national level to scale up the intervention is essential from the start if the intervention is found to be successful.

? Strong partnership from the beginning can result in sense of ownership among a wide range of partners and facilitate more rapid adoption and expansion.

? Surveys on prevailing practices for managing the third stage of labor are powerful advocacy tools.

 

Resources: 

Advance Distribution of Misoprostol for Self-Administration: Expanding Coverage for the Prevention of Postpartum Hemorrhage, Program Implementation Guide: Revised, November 2013

This new program guide was developed in 2013 to support expansion of programs focused on advance distribution of misoprostol for PPH prevention.It is designed to help program and technical staff from NGOs and INGOs develop programs in new areas in support of existing Ministry of Health safe motherhood programs, moving through three phases of program planning and implementation.

It is similar to the 2009 guide that supports introduction of misoprostol for PPH prevention, that also is available in this toolkit.

This is the revised version of this guide, November 2013 and contains all annexes in the main pdf file. Additionally, the annexes are posted as a separate file below in Word in case they need to be adapted.

Program Brief: PPH Prevention and Management

This 2-page MCHIP program brief summarizes the key facts, issues and interventions for PPH prevention and management and it is aimed at policymakers. It is complemented by the advocacy presentation.

Program Implementation Guidance: PPH Prevention and

Management

This guidance document was developed to assist program teams to develop projects and interventions to address PPH. It directs users through a series of steps and guides them on where to access relevant resources in the toolkit.This version was updated in December 2011.

WHO Recommendations on Prevention and Treatment of Postpartum Haemorrhage: Highlights and Key Messages from New 2012 Global Recommendations

This brief provides a summary of the new 2012 WHO PPH Guidelines, highlighting new and revised practice based on the latest evidence. You can find the full PPH guidelines and eveidence base are posted in Section 4 of this toolkit.

Active Management of the Third Stage of Labour: New WHO recommendations help to focus implementation

This 2-page brief summarizes what is new and different on AMTSL based on the new 2012 WHO PPH guidelines. Available in four languages.

Prevention of Postpartum Hemorrhage at Home Birth: A Community-focused Approach Using Birth Preparedness and Misoprostol

This MCHIP brief presents the evidence and experience of PPH prevention for both fcaility- and community-based births. It details a strategic approach in 8 points for PPH prevention at home births.

Policy Brief: Scaling up Misoprostol for Postpartum Hemorrhage: Moving from Evidence to Action. FCI (2012) (English and French)

This useful policy brief explores strategies to help governments and their partners reduce maternal mortality by expanding access to misoprostol for PPH. Importantly, this briefer highlights key elements for introducing misoprostol for PPH, including creating a supportive national policy; including misoprostol in national health budgets; preparing and disseminating national clinical guidelines; training health workers; ensuring consistent supply and distribution; and building community awareness and demand.

Preventing Postpartum Hemorrhage at the Community Level: A compendium of operations research

This compendium summarizes the results from a series of VSI-led independent operations research programs across seven programs in Africa and Asia between 2008 and 2012.  The goal of these programs was to determine the feasability, acceptability, and program effectiveness of misoprostol use to prevent PPH at the community level. This report summarizes the country findings from Bangladesh, Ghana, Nigeria, Tanzania, Kenya, Zambia, Mozambique, as well as identifies several facilitating factors that contributed to program success that can increase the likelihood of scale-up on a national level. These factors include strong government support; high levels of antenatal care coverage; the identification of local methods to measure blood loss; and the adaptability of program methods to the local context.

PPH Technical Brief: PPH Prevention and Management

This MCHIP technical brief summarizes the current clinical evidence for country programs to consider when addressing PPH is a priority to reduce maternal mortality. There is a range of both well-known and emerging prevention and management interventions available?in addition to broader strategies such as skilled birth attendance, birth preparedness, and emergency obstetric care?to countries to address their specific settings and challenges. Because the reality for most women in developing countries is that they have no access to skilled birth attendance or facility based intrapartum care.

Prevention and Management of Postpartum Hemorrhage and Pre-Eclampsia/Eclampsia: National Programs in Selected USAID Program-Supported Countries

A country-level landscape analysis was conducted from January to March 2011 in 31 countries across Africa, Asia and Latin America, including 23 MCHIP priority countries facing

the highest disease burden. The purpose of this analysis was to document progress in national scale-up of PPH- and PE/E-reductionprograms in all MCHIP and MCHIP-affiliated programs around the world. It is anticipated that the questionnaire used in this analysis will be repeated on a semi-annual to annual basis in an effort to maintain current information.

Interventions for Impact in Essential Obstetric and Newborn Care Africa Regional Meeting Report, 21?25 February 2011

This meeting covers covers the content, discussions and recommendations from the regional meeting held in Addis Adaba in February 2011. The report includes: 1)  interventions for impact in obstetric health; and 2) helping babies breathe (HBB) regional training of trainers (TOT) for Africa.

Annotated Bibliography: Postpartum Hemorrhage: Prevention and Management

This annotated bibliography is the result of an evidence review of nearly 200 articles on topics related to postpartum hemorrhage (PPH) prevention and management. After an extensive technical review, the 20 most important articles are abstracted in Section 1 to highlight the key findings and implications for public health programming. Other important articles are listed as references in Section 2.

WHO Statements regarding the Use of Misoprostol for Postpartum Hemorrhage Prevention and Treatment

These 2 statements by WHO explain the current WHO position regarding misoprostol use after childbirth to prevent PPH and should be read together. WHO recommends the use of misoprostol in settings where it is not possible to use oxytocin or another injectable uterotonic. Health workers who will administer misoprostol should be trained in its correct use after birth of the baby and to avoid its administration before birth at incorrect doses, and in identifying and managing its side-effects. WHO has taken a cautious approach regarding community-based distribution of misoprostol for home births and recommends rigorous research.

Technical Report: Final Assessment on the Feasibility of Auxillary Midwives Using the AMTSL in Mali

This assessment aimed at documenting the efficiency and the safety of matrones using AMTSL in the prevention of PPH in order to extend this procedure to all regions. The data from the final evaluation has been compared with the information gathered during the baseline survey in order to evaluate the changes that occurred, after the intervention, in the providers? practice, with a particular focus on matrones. The evaluation results show that the intervention has led to changes in terms of knowledge and, above all, performance levels displayed by providers, especially by matrones, in AMTSL practice. Additionally, the evaluation results show that matrones are just as efficient as skilled birth attendants.

Preventing Postpartum Hemorrhage

This 4-page brief presents evidence on PPH prevention for two contexts: when women give birth with skilled provider at home or in a facility. Where there is a skilled provider: one of the most important prevention measures is having a skilled provider present at birth. In addition to using the WHO partograph to monitor labor, the appropriately trained skilled provider is less likely to perform procedures such as episiotomy or operative vaginal delivery without clear indications. Finally, the skilled provider can perform AMTSL in order to prevent uterine atony, the most common cause of immediate PPH. Where there is no skilled provider, misoprostol may also offer a solution for home births attended by a provider not qualified to perform AMTSL.

Postpartum Hemorrhage: A Challenge to Safe Motherhood

This advocacy brief is aimed at policymakers to generate support for addressing PPH.

Joint Statements from FIGO/ICM on Prevention of Postpartum Hemorrhage

ICM and FIGO have jointly released 3 statements about PPH prevention:1. A 1-page statement that active management of the third stage of labour is proven to reduce the incidence of postpartum haemorrhage, the quantity of blood loss, and the use of blood transfusion. AMTSL should be offered to women since it reduces the incidence of

postpartum haemorrhage due to uterine atony. FIGO/ICM will promote active management of the third stage of labour and take action to prevent postpartum haemorrhage.2. a 2-page statement (2003) detailing the importance of AMTSL to prevent PPH, as well as how to provide AMTSL3. a 4-page statement in 2006 on the new advances for PPH prevention and treatment in low resource settings 

Misoprostol for Prevention of Postpartum Hemorrhage: An Evidence-based Review by the United States Pharmacopeia

This publication discusses the evidence regarding the use of misoprostol for the prevention of postpartum hemorrhage and based on their review of studies, the consensus of the U.S. Pharmacopeia Expert Advisory Panel is that the prevention of PPH should be considered as an accepted indication in the USP Drug Information (DI) monograph on misoprostol. They recommended misoprostol as an alternative agent in reducing the incidence of PPH , especially in situations in which oxytocin and other uterotonic drugs are not available, such as in developing countries.

Scope of Work for the Prevention of PPH at Home Births Technical Advisory Group (TAG)

This SOW defines 2 phases of teechnical advisory group support to the MOH on PPH prevention for home births. It can be adapted by other countries seeking to establish a TAG.

Respectful Maternity Care: The universal rights of childbearing women

The White Ribbon Alliance for Safe Motherhood addresses disrespect and abuse during maternity care with advocacy documents and a charter for maternal human rights.

PresentationsResources: 

PPH Advocacy Presentation: Postpartum Hemorrhage

This advocacy presentation was developed by MCHIP to capture the key issues for policymakers on PPH prevention and management.

Postpartum Hemorrhage Prevention and Management: Evidence and Action

This MCHIP technical presentation was developed as a resource to: describe the global mortality burden of PPH; present current evidence and action to prevent PPH; share key evidence and action to manage PPH; and discuss key elements in a comprehensive program to reduce deaths from PPH.

Step 2: Create Enabling Policy Environment

To improve care for women and the ability of providers to prevent and manage PPH, an adequate enabling environment?including resources and policies?must be established.

Integrate PPH-relevant interventions where possible: Working through the national PPH TAG, integrate PPH strategies into existing maternal and newborn health programs to increase the likelihood that interventions for PPH are sustainable and are integrated rather than vertical. The strategy will need to define stages or phases for implementation at all levels along the continuum of care. With the range of PPH prevention and management interventions, integration into existing services, trainings, behavior change communication campaigns, and management information systems (MIS) will expand coverage and save resources.

Combine approaches for greater impact: Policies need to define the PPH-related interventions that are authorized at each level of care (including the home) and by each type of birth attendant (including a family member or the woman herself). Based on the national situation, governments may need to make decisions about which approach to promote at each point of care (home to facility) and by each type of birth attendant (family member or traditional birth attendant to SBA). For example, in settings where a large proportion of births are not attended by SBAs, distribution of misoprostol through antenatal care (ANC) clinics may be promoted. This approach will only be effective, however, if most women attend ANC late in pregnancy when misoprostol could be distributed. In Tanzania, 92% of women presented early in pregnancy for an ANC visit, but only 52% visited after 32 weeks and received misoprostol.4 A modeling exercise for sub-Saharan Africa estimated that a comprehensive intervention package (health facility strengthening and community-based services) would reduce deaths due to PPH or sepsis after delivery by 32%

(compared to just health facility strengthening alone [12% reduction]).5

Develop policies that allow a range of providers to offer PPH-related care: Policies need to be in place that ensure access to PPH prevention and treatment interventions by all women giving birth, regardless of the type of birth attendant or the place a woman chooses to give birth. To do this, policies must support authorization of different cadres of providers to provide defined interventions for prevention and treatment of PPH. For example, in 2009, the Ministry of Health in Mali decreed that AMTSL and oxytocin could be used for the prevention of PPH by doctors, midwives, obstetric nurses and matrons (auxiliary midwives), increasing national coverage of AMTSL.

Ensure that service delivery guidelines are up to date: National service delivery guidelines should reflect state-of-the-art and evidence-based interventions for prevention and treatment of PPH. These may be adapted from global reference materials, such as publications developed by the WHO. Ministries of Health need to disseminate copies to all levels of the health care system to ensure compliance with the guidelines.

Address logistics needs for drugs, instruments and equipment: Ensure both oxytocin and misoprostol are on the national Essential Drugs List and are tracked through national logistics management information systems. Although misoprostol is often available in countries for other uses, registration of the drug for importation and use for PPH prevention and treatment is needed.

Program Pitfalls and Lessons Learned: Policy for PPH Programming

? Having a clear understanding of PPH prevalence by place of birth and type of birth attendant will greatly assist policy makers in defining policy for ensuring maximum access to PPH prevention and treatment interventions.

? Ensuring the integration of PPH-related interventions into broader maternal and newborn health programs will ensure maintenance and sustainability.

? Policy should ensure uterotonic drug coverage for all births, including births in vulnerable and marginalized populations.

? To ensure access to PPH prevention and treatment interventions, MOH policies need to promote provision of selected interventions at all points of care and by all types of birth attendants.

? The most effective way to prevent PPH and reduce morbidity and mortality from PPH is to promote attendance by SBAs for all births. However, countries with high rates of home deliveries without a skilled provider may need to provide additional focus on PPH prevention at home births until more births are attended by SBAs.

? If a large proportion of births are not attended by skilled providers and there is an existing network of community health workers (CHWs) or volunteers, it is possible to work with existing community-based providers and networks to achieve high coverage of PPH prevention and to reach disadvantaged segments of the community at higher risk of poorer outcomes.6

? Policies cannot be implemented unless logistical and training concerns are first addressed.

? For new projects or studies involving misoprostol, it is important to identify the source of sufficient quantities of tablets as well as to address drug registration issues.

? Use all of the available resources and materials to facilitate implementation?training and counseling materials, program implementation guides, evaluation tools and posters.

 

Resources: 

Prevention of PPH at Home Births: Program Implementation Guide

This guide is designed to help service providers and publich health decision-makers act now to being implementing programs that use community-based distribution of misoprostol as a tool in the fight against maternal mortality. Decades of research have proven the safety and efficacy of misoprostol. This guide will help service providers creat programs that reach the most vulnerable populations of women?those who live in rural areas and who are unable to access a skilled birth attendant to assist with delivery. It has been developed to provide the managers of RH programs with a step-by-step guide to setting up a community-based misoprostol program. It provides reality-based guidance for a country specific adaptation of misoprostol distribution.

Planning Tool for Expanding Access to AMTSL: A Guide

for Program managers and Donors

This planning tool was developed by the POPPHI project team to assist governments and organizations to identify their place on the continuum of critical elements needed to ensure universal access to AMTSL, identify gaps between where they are and where they need to be to have an environment that promotes AMTSL, and identify the types of interventions needed to assist in increasing the percentage of women who are offered and receive AMTSL during vaginal deliveries.

Advancing Maternal and Newborn Health in Malawi, Women Deliver Conference 8 June 2010

In Malawi, the Ministry of Health is focusing on the reduction of maternal, neonatal and child mortality towards the achievement of the Millennium Development Goals through targeted high-impact interventions at the facility and community levels.  In collaboration with its maternal and newborn health (MNH) partners at the community level and with facilities in all 28 districts, the MoH promotes quality of reproductive health (RH) services including infection prevention (IP) and control practices, Basic Emergency Obstetric and Neonatal Care (BEmONC), and community-based MNH interventions along the Household to Hospital Continuum of Care (HHCC). In 2005, a Nationwide Assessment by the MoH exposed significant gaps in the delivery of BEmONC and Comprehensive Emergency Obstetric and Neonatal Care with only two BEmONC sites nationally (0.1 per 500,000 population).  Quality of RH services remain a cross-cutting focus of the MoH.  Since 2006, the MoH has worked with Jhpiego to develop a performance and quality improvement (PQI) approach which implements integrated national IP and RH standards for application at both hospital and health center levels. The PQI/RH model has been established in 16 district hospitals, all four central hospitals and is being piloted in 12 health centers; with plans to scale up countrywide to government hospitals in the remaining 12 districts.  Two hospitals, Mzuzu Central Hospital and Mchinji District Hospital have been recognized as Centers of Excellence in RH service delivery.

Clinical and Community Action to Address PPH Toolkit

Pathfinder has developed a toolkit, a collection of resources to support implementation of the Clinical and Community Action to Address PPH model. Due the the toolkit size, a link is provided here as well as the Table of Contents.

Preventing PPH: Why Quality Improvement Matters

Reliable administration of AMTSL depends on essential health system functions that are often weak in high-mortality settings?hence the common failure of health services to deliver AMTSL even when endorsed by official standards. QI approaches such as the improvement collaborative are an effective strategy for strengthening essential health system functions to accelerate scale-up of AMTSL and other high impact interventions and should be a part of every maternal and newborn health program.

Strategy for the Reduction of Morbidity and Mortality from Postpartum Haemorrhage

This national strategy document covers the following essential care areas to reduce maternal mortality and morbidity due to PPH in situations both with and without a skilled birth attendant:1. Preventing PPH in Situations WITHOUT a Skilled Birth Attendant2.Managing PPH in Situations WITHOUT a Skilled Birth Attendant3. Preventing PPH in Situations WITH a Skilled Birth Attendant4. Management of PPH in Situations WITH a Skilled Birth Attendant

Creating Access to Misoprostol: Steps to Availability

This 1-page flowchart outlines the steps for policy, registration, guidelines, drug procurement and public & private sector implementation.

Estimation of Uterotonic Use Immediately After BirthResources: 

Guidelines for Estimating National Coverage of Uterotonic Use Immediately Following Birth

These guidelines were developed by MCHIP to facilitate a meeting of the national experts to reach a consensus on the estimate of national coverage for uterotonic use immediately following birth.

UTEROTONIC USE IMMEDIATELY FOLLOWING BIRTH: New Methodology for Estimating National Coverage

This 2-page briefer presents the methodology used to estimate national coverage of uterotonic use immediately after birth (UUIFB) and the results from its use in three countries.

Step 3: Prepare Providers to Deliver Care

Ensuring that health care providers have adequate knowledge and skills improves the quality of the entire health care system.

Develop clinical champions for PPH interventions: To change clinical practices and attitudes, it is helpful to have clinical leaders at the facility level who are convinced of the evidence and can persuasively convince their peers during the implementation process.

Conduct a training needs assessment: Although most low and middle income countries have been working to reduce maternal mortality through strengthening SBA, BEmONC and CEmONC training, a systematic training needs assessment for all relevant PPH interventions and all types of providers can be useful to prioritize remaining gaps in the training system.

Disseminate simple and adapted job aids during training: Job aids can greatly assist providers in transferring learning to their work site and maintaining standards of care. Job aids could include those for developing a birth preparedness plan (including speaking to the importance of giving birth with an SBA, so as to receive AMTSL), AMTSL, monitoring in the immediate postpartum, storage of uterotonics, and quantification for uterotonics (see Section 4 for available job aids).

Develop a training strategy and strengthen training sites: Based on the training needs assessment findings, any existing pre-service and/or in-service training strategy for SBA, BEmONC and CEmONC can be updated to ensure all aspects of PPH are addressed.

? Training sites may need to be assessed and strengthened to ensure classroom teaching and clinical practices appropriately teach PPH prevention and management.

? Where appropriate and possible, develop alternate training strategies, such as the site and individual (SAIN) learning approach, to reduce cost, increase effectiveness, and increase access

to training activities.

? Link managers, pharmacists and clinicians to ensure that supplies and drugs are available to practice AMTSL safely, thus increasing the likelihood that training is transferred to the work site.

Program Pitfalls and Lessons Learned: Human Resource Development

? Many countries have guidelines and training curricula in place supporting AMTSL within broader maternal and newborn health training initiatives. Other newer PPH interventions may not yet be included, but the effective processes from AMTSL work can be utilized.

? National priorities should focus on human resource development and include training strategies to improve the knowledge and skills of health care workers; all cadres of providers attending births need to be included in a training strategy.

? Sufficient resources are needed for training and supervision to improve provider skills, performance and quality of care (QOC).

? Competency-based and humanistic training approaches must ensure that all participants have the ability to develop clinical skills in actual clinical environments with patients. Before doing so, it is necessary to provide them with the chance to practice in simulated settings with anatomic models.

? Task-shifting to lower level cadres is essential to increasing uterotonic coverage, especially where SBAs are not available. Community-based approaches should be a priority and CHWs should be included in training plans.

Resources: 

Evaluation of Training Strategies for Management of the Third Stage of Labor

POPPHI conducted a small evaluation to review available training strategies. This report summarizes the evaluation, outlines relevant resources, and presents preliminary recommendations based on evaluation findings. An appendix includes a list of technical and training resources including, web links, training documents, and other relevant resources used in the evaluation.

Competency-Based Checklists

As part of the Pathfinder Clinical and Communiy Action to Address PPH toolkit, this resource

contains 3 competency-based clinical checklists: 1) AMTSL; 2) Estimating blood loss and using the blood collection drape; 3) applicaiton and removal of the non-pneumatic anti-shock garment (NASG).

Training MaterialsResources: 

Prevention of PPH AMTSL: On-site and Individual (SAIN) Learning Approach

The on-site and individual (SAIN) learning package on the prevention of postpartum hemorrhage consists of 2 sets of materials: 1) Facilitators materials to develop mentors; and 2) mentors materials to assist learners. This learners package was developed for use by nurses, midwives, and doctors providing childbirth and immediate postpartum care. It can be used for in-service training of skilled birth attendants using a mixed- or blended-learning approach that combines self-paced study for the theoretical portion of the course followed by a clinical practicum. This training course should assist providers in offering the crucial care needed to prevent PPH.See the POPPHI website for the full set of materials in English and French, including presentations (http://pphprevention.org/SAIN).

Prevention of PPH AMTSL Training Package

POPPHI developed a learning package on the prevention of postpartum hemorrhage consisting of a reference manual, participant?s notebook, and facilitator?s guide. This learning package was developed for use by nurses, midwives, and doctors providing childbirth and immediate postpartum care. This course is designed to be utilized for in-service training, with the overall objective of  providing updates about AMTSL use to equip nurses, midwives, and clinical and health workers.See the POPPHI website for more resources and information about this course, French edition and Word versions of these manuals (http://pphprevention.org/AMTSLlearningmaterials.php)

Sample training schedules for providers and CHWs (Annex B and C of the Program Implementation Guide for

Advance Distribution of Misoprostol, 2013)

Annex B contains the 5-day course syllabus and schedule for training facility-based providers on PPH prevention and management in the context of a advance distribution of misoprostol program area. Annex C is a 4-day course syllabus and schedule for CHWs/TBAs on PPH prevention for advance distribution of misoprostol programs.

Word file is attached for easy adaptation; see both annexes and guidance on how best to use and adapt them in the full program implementation guide.

Prevention, Recognition, and Management of Postpartum Hemorrhage Training Package

This training package can be used to train health care professional in the skills needed to create a continuum of care for PPH prevention and management. It is part of the Pathfinder PPH Toolkit for Clinical and Community Action to Adress PPH. It includes a trainers guide and participants guide.

Managing the Third Stage of Labor in Peripheral Health Care Settings: A Guide to Train Auxillary Midwives

This flipchart was developed in the African context to help train auxiliary midwives to apply active management of the third stage of labor (AMTSL). It contains cards with illustrations in a binder format showing the steps for AMTSL and monitoring the woman and the newborn in the immediate postpartum period. The flipchart is designed to support training of low-literate birth attendants and presents key messages for applying AMTSL.

Integrating AMTSL and Immediate Postnatal Care (PNC) Training Package

This learning package for integrating active management of the third stage of labor (AMTSL) and immediate postnatal care (IPNC) consists of a reference manual, a participant?s notebook, and a facilitator?s guide. This learning package was developed for use by nurses, midwives, and doctors providing childbirth and immediate postpartum care for the woman and newborn in peripheral health care facilities.See the POPPHI website for more resources (presentations) and information on this course (http://pphprevention.org/IntegratingAMTSLandimmediatepostnatalcare.htm).

Managing PPH (Midwifery Education Module)

This midwifery module is part of the World Health Organization (WHO) education materials to facilitate the teaching of the midwifery skills required to respond to the major causes of maternal death. It has 11 sessions focused on PPH and includes clinical skills followed by case studies.

Managing Complications in Pregnancy and Childbirth?A Guide for Midwives and Doctors

As part of the WHO Integrated Management of Pregnancy and Childbirth series, the MCPC is a reference manual intended for use by midwives and doctors at the district hospital iwho are responsible for the care of women with complications of pregnancy, childbirth or the immediate postpartum period, including immediate problems of the newborn. While most pregnancies and births are uneventful, all pregnancies are at risk. Around 15% of all pregnant women develop a potentially life-threatening complication that calls for skilled care and some will require a major obstetrical intervention to survive. The interventions described in these manuals are based on the latest available scientific evidence.  It is hoped that this manual will be used at the side of the patient, and be readily available whenever a midwife or doctor is confronted with an obstetric emergency.In addition to the care midwives and doctors provide women in facilities.

Online Training CoursesResources: 

Preventing Postpartum Hemorrhage: Online Course,

USAID Global Health e-Learning Center

This online course is offered by the USAID Global Health e-Learning Center and is free to take. This course will orient you to the causes of PPH and the evidence-based methods of preventing PPH. It will take approximately 1 hour, 15 minutes to complete. Course objectives inlcude: 

Describe the contribution of PPH to maternal mortality globallyDiscuss the causes of PPHDescribe healthy practices during pregnancy that help prevent mortality from PPHDescribe some healthy practices during the first and second stages of labor that help prevent PPHDescribe active management of the third stage of labor (AMTSL), the key evidence-based practice for preventing PPHDiscuss physiologic versus active management of the third stageDiscuss the evidence for the practice of AMTSLDiscuss the cost issues involved with AMTSLDiscuss the drugs that may be used in performing AMTSLDiscuss the importance of vigilant monitoring during the ?fourth stage? of labor (immediately postpartum)Describe the elements involved in country-level implementation (integration into a national Safer Motherhood program) of an AMTSL componentDiscuss training considerations involved with performing AMTSLDiscuss drug management issues in institutionalizing AMTSLDiscuss challenges involved with the introduction of AMTSL

 

Active Management of the Third Stage of Labor: A Demonstration

This animated online video takes you through the steps of AMTSL.

Step 4: Improve Quality of Care

Clinical care and treatment guidelines for prevention of PPH?along with a practical management approach for improving the performance and quality of health services?lead to meaningful, sustainable improvements in health care. Country?s key stakeholders, decision-makers and other leaders should work together to ensure responsiveness to the country?s needs and to

foster the broad acceptance necessary for implementation by health care providers.

Ensure QOC tools exist and are in use: Approaches to ensure quality implementation of programs for PPH prevention and management are needed, regardless of whether the programs focus on household- or hospital-based service delivery. Programs have used various approaches, such as Standards-Based Management and Recognition (SBM-R), Client-Oriented, Provider-Efficient Services (COPE) and Improvement Collaborative to support this process. Providers at each level of the service delivery system need to have clear performance standards, as well as the support and resources to implement them. The process of promoting improved quality is equally important to facilitate and sustain change (such as described in the SBM-R process). The process will also support/strengthen supervision, infection prevention and logistics systems.

Monitor QOC across sites/facilities: When using a common set of QOC standards, it?s possible to compare quality at a single site over time or across multiple sites/facilities. This allows government, donors and stakeholders to see progress and identify areas where improvements are still needed. It also helps motivate staff and create healthy competition among facilities.

Strengthen logistics systems to plan and procure sufficient commodities to meet QOC standards: Providers need to have sufficient quantities of oxytocin and other medications and supplies for PPH prevention and treatment. As an example, too often districts only order enough oxytocin to treat hemorrhage, rather than enough to give every woman a dose during AMTSL.

Identify and address providers? barriers to PPH prevention and management: Provider behaviors and attitudes toward PPH prevention and management need to be addressed. Job aids are practical behavior change communication tools to overcome barriers for providers.

Program Pitfalls and Lessons Learned: QOC

? Approaches to improve QOC have led to rapid increase in the use of AMTSL.

? Providers may be more motivated to offer AMTSL to all women at the time of birth if they are required to document its use in a formal hospital record.

? Availability of appropriate drugs is vital for quality care; when providers return to a facility where these drugs are not available, transfer of learning is hampered. Follow-up supervision should be in place to ensure essential resources.

? AMTSL guidelines are often only available at the BEmONC trainings. To achieve improvement in QOC, the guidelines should be widely and proactively disseminated.

? Frequent transfer of providers requires ongoing in-service training and innovative approaches to maintaining skills and knowledge among all providers at a site.

Resources: 

WHO Recommendations for the Prevention and Treatment of Postpartum Hemorrhage

These updated guidelines from WHO include 32 recommendations for PPH prevention and management, including the recommendation that "In settings where skilled birth attendants are not present and oxytocin is unavailable, the administration of misoprostol (600 ?g PO) by community health care workers and lay health workers is recommended for the prevention of PPH."

Note this document replaces several WHO guidelines previously posted in this toolkit:  WHO Recommendations for the Prevention of Postpartum Haemorrhage (2006); WHO guidelines for the management of postpartum hemorrhage and retained placenta (2009);

Prevention of Post-partum Haemorrhage with Misoprostol: FIGO Guideline, Annotated Version. International Federation of Gynecology and Obstetrics (2012)

This annoted version of the 2012 FIGO guidelins summarizes the background evidence regarding the use of misoprostol for the prevention of post-partum haemorrhage (PPH), discussing both misoprostol versus coventional injectible uterotonics and misoprostol in the prevention of PPH in situations where there is no  access to oxytocin. These guidelines also describe the recommended dosage, course of treatment, contraindications, and side effects, as well as discuss reports from ongoing programs in which women are given misoprostol tables for self-administration after delivery in settings where oxytocin is not available.

Treatment of Post-partum Haemorrhage with Misoprostol: FIGO Guideline, Annotated Version. International Federation of Gynecology and Obstetrics (2012)

This annotated version of the 2012 FIGO guidelines summarizes the background evidence regarding the use of misoprostol for the treatment of post-partum haemorrhage (PPH). These guidelines also describe the recommended dosage, course of treatment, the effect of repeat or consecutive doses, contraindications, precautions, effects and side effect. 

Country Example - Clinical Guidelines for the Prevention and Management of Postpartum Haemorrhage in South Sudan. MOH, Government of the Republic of South Sudan (2013)

These 2013 official clinical guidelines describe key PPH prevention interventions- for both facility and community based births. They also outline the general management of PPH, including uterotonics that can be used, and the diagnosis and management of PPH after childbirth according to specific causes.    

CHW supervision checklist (Annex E of the Program Implementation Guide for Advance Distribution of Misoprostol, 2013)

This CHW supervision checklist helps provide supportive supervision for CHWs in advance distribution of misoprostol programs.

Word file is attached for easy adaptation; see the annex and guidance on how best to use this tool in the full program implementation guide.

Guidelines for the Use of Uterotonic in Active Management of Third Stage of Labor (AMTSL)

This national document outlines the steps of AMTSL and defines some of the "ways forward" to ensure AMTSL is provided.

Integrated Management of Pregnancy and Childbirth: Pregnancy, Childbirth, Postpartum amd Newborn Care?A Guide for Essential Practice

This guide aims to provide evidence-based recommendations to guide health care professionals in the management of women during pregnancy, childbirth and postpartum, and post abortion, and newborns during their first week of life, including management of endemic

diseases like malaria, HIV/AIDS, TB and anaemia. It is a guide for clinical decision-making. It facilitates the collection, analysis, classification and use of relevant information by suggesting key questions, essential observations and/or examinations, and recommending appropriate research-based interventions. It promotes the early detection of complications and the initiation of early and appropriate treatment, including timely referral, if necessary.

Performance and Quality Improvement (PQI)Resources: 

Performance Standards for Reproductive Health: Area 3: Management of Complications during Labor and Delivery

This set of performance standards focuses on managing complications during labor and delivery including the management of PPH. It is part of a larger set of standards developed by the Malawi Ministry of Health on reproductive health services.

Standard-Based Management and Recognition: A Field Guide

This field guide is intended to provide some help with the task of improving the delivery of health service usign standards of care as the basis for improvement. This Guide is designed to answer questions such as: What types of standards are really useful to local providers and managers? How can they be in a practical way? How can the improvement process be supported?

Site Assessment and Strengthening for MNH Programs

This toolkit presents a process and tools that can be used to conduct facility-level site assessment and strengthening (SA/S) with the goal of improving essential maternal and newborn care services. The SA/S activity is based on the performance improvement process defined by the USAID Performance Improvement Consultative Group, and adapted by JHPIEGO as a performance and quality improvement (PQI) approach. It provides an overview of how the PQI process can be used to strengthen facility and individual performance and how it can be easily and effectively incorporated into the operating norms of

any facility. Using the PQI process described in this toolkit, staff can continually assess and strengthen individual and facility-level performance.

Quality Improvement for Emergency Obstetric Care

This package was developed and used in the AMDD program and contains 2 books: 1) a toolbook contains a set of tools and instructions for use in gathering and analyzing information to assess the quality of care in EmOC facilities. With the information gathered through these tools, staff  can work together as a team to identify problems and implement solutions according to the continuous QI process. 2) a leadership manual for staff working at EmOC facilities.

Using PQI to Strengthen Skilled Attendence

This brief summarizes the MNH Program experience using PQI processes to improve the quality and demand for maternal and newborn care.

Job aids for ProvidersResources: 

Active Management of the Third Stage of Labor (AMTSL)

This poster graphically depicts the 3 steps of AMTSL with simple drawings and reminders.

Wall Chart: AMTSL

This pathfinder wall chart presents algorithms for the 3 steps of AMTSL. It is part of the Clinical and Commnity Action to Adress PPH toolkit.

Wall charts: Managing Hypovolemic Shock using the NASG

There are 3 wall charts developed by Pathfinder as part of their Clinical and Community Action to Address PPH toolkit: 1) Management of Hypovolemic Shock; 2) Removing the NASG; and 3) Cleaning the NASG. Additionally there is a job aid "Recommended Dilutions of Sodium Hypochloride (Bleach) for Decontaminating the NASG.

Wall chart: Estimating Blood Loss

This wall chart includes photos to help providers estimate blood loss from PPH.

Wall chart: Using the Blood Collection Drape

This pictoral wall chart guides a provider through the 9 steps of using a blood collection drape as part of PPH care.

Steps for AMTSL for Low-Literate Birth Attendants

This pictoral AMTSL job aid is designed for low literate birth attendants. Drawings are of the African context.

Integrating AMTSL and Essential Newborn Care

This 1-page job aid is an algorithm for essential newborn care.

Algorithm for the Management of Postpartum Hemorrhage

This job aid begins with an algorithm on the front side for managing PPH. The reverse side details the clinical skills required with some graphics.

Management of PPH

This simple 2-page job aid for providers covers the: definition of PPH; causes highlighting the 4 Ts; and general management. The back side inlcudes pictoral PPH management steps and a table of relevant drugs and doses.

Immediate Action in Case of Excessive Bleeding after Childbirth

This pictoral job aid covers: immediate action; non-surgical management of uterine atony after childbirth; management of excessive bleeding without an identified cause; and surgical interventions.  

Postpartum Hemorrhage Management

This Powerpoint presentation of 4 slides presents an algorithm for PPH management.

Drugs & LogisticsResources: 

Fact Sheet: Uterotonic Drugs for the Prevention and Treatment of PPH

This fact sheet covers uterine stimulants (uterotonics or oxytocics), medications given to cause a woman's uterus to contract, or to increase the frequency and intensity of the contractions. It details the common drugs, the evidence, use and costs.

Global Misoprostol Registration by Indication (map & detailed spreadsheet). VSI. May 2013

VSI prepared this useful map to show the status of regulatory approvals of misoprostol globally.  This map highlights the various types of indications misoprostol is approved for,

such as PPH, other obstetic indications, gastric ulcers, etc.

Forecasting Misoprostol Tablets for Postpartum Hemorrhage (PPH) Prevention and Treatment in Liberia

This Excel spreasheet file is a forecasting tool for misoprostol for PPH prevention and treatment. It is an example from Liberia, provided by VSI, but can be adapted for use in other country programs.

Misoprostol for Maternal Health

The Caucus on New and Underused Reproductive Health Technologies is a community of practice established under the auspices of the Reproductive Health Supplies Coalition, for which PATH serves as Secretariat. Caucus members developed this series of peer-reviewed briefs on underused reproductive health technologies. This brief details efficacy, current program use, manufacturers and suppliers, registration status, and public-sector price agreements for misoprostol.

Oxytocin brief

The Caucus on New and Underused Reproductive Health Technologies is a community of practice established under the auspices of the Reproductive Health Supplies Coalition, for which PATH serves as Secretariat. Caucus members developed this series of peer-reviewed briefs on underused reproductive health technologies. This brief details efficacy, current program use, manufacturers and suppliers, registration status, and public sector price agreements for oxytocin.

International Drug Price Indicator Guide

The International Drug Price Indicator Guide provides exactly what the name implies -- an indication of drug prices on the international market. The guide focuses on medicines on the WHO List of Essential Medicines, which includes misoprostol.

MSH, in collaboration with WHO, is working with partners to make existing drug price information more widely available in order to improve procurement of medicines of assured quality for the lowest possible price. This will contribute to equitable access to health services and commodities, including essential medicines, necessary for the prevention and treatment

of prevalent diseases

Quantification of Health Commodities: A Guide to Forecasting and Supply Planning for Procurement

This guide for quantification of health commodities has been developed to assist technical advisors, program managers, warehouse managers, procurement officers, and service providers in (1) estimating the total commodity needs and costs for successful implementation of national health program strategies and goals, (2) identifying the funding needs and gaps for procurement of the required commodities, and (3) planning procurements and shipment delivery schedules to be able to ensure a sustained and effective supply of health commodities. The step-by-step approach to quantification presented in this guide is complemented by a set of product-specific companion pieces that provide detailed instructions for forecasting consumption of ARV drugs, HIV test kits, antimalarial drugs, and lab supplies.

This guide was developed by the USAID DELIVER Project, implemented by JSI.

Selection of Uterotonic Drugs in Tropical Climates

AMTSL requires the administration of a uterotonic drug immediately after birth of the newborn, and before delivery of the placenta, to prevent postpartum hemorrhage (PPH). The decision on which uterotonic to use will depend on many factors, including: cost; efficacy; stability; response time; adverse effects; contraindications; and requirements for administering the drug.

Rational Use of Uterotonic Drugs during Labor and Childbirth

This POPPHI manual covers the essentials of uterotonic use including: use during labor and childbirth; preparation and steps of AMTSL; integration of AMTSL; storage; and management of excessive bledding after childbirth.

Drug Management Issues in AMTSL

This brief addresses a range of uterotonic drug management issues.

Management of Uterotonic Drugs: Documenting the Movement of Uterotonic Drugs

This simple 1-page job aid guides uterotonic drug logistics in a facility from the pharmacy to the delivery room. It also addresses disposal of expired or broken stock.

Storage of Uterotonic Drugs in the Pharmacy

This 2-page job aid helps staff in the pharmacy ensure proper storage of uterotonic drugs.

Step 5: Increase Awareness Among Women and Their Families

Mobilizing families and communities increases demand for services, a vital step in improving care for mothers and newborns. When women and their caregivers understand potential dangers and are prepared, it leads to better outcomes.

Identify women?s, families? and communities? understanding of the problem and barriers to action: In countries where PPH is a major killer, especially at home births, the problem is often well-known, but recognizing when bleeding is too much and accessing life-saving care are barriers. Often barriers to PPH prevention and management are larger economic, geographical or cultural issues. National behavior change communication or community mobilization strategies will likely address most barriers, but those specific to PPH prevention seeking behaviors need to be explored and integrated.

Develop tools, materials and activities to address barriers and mobilize communities:Communication messages, materials and activities focused on behavior change for PPH prevention and management can be developed and integrated into existing maternal and newborn health campaigns, reaching pregnant women and their families.

? In addition, in most countries where misoprostol was distributed for PPH prevention at home births, behavior change communication activities are planned to help name or brand and position the packet of tablets (such as ?Immediate Response to Hemorrhage [perdarahan atasi segara]? in Indonesia; ?Tablet against PPH [Golee Zed-e- Khoon Reyzee Bad Az Wiladat]? in Afghanistan; and ?Mother?s Protection Tablet [matri suraksha chakki]? in Nepal).

Link communities and facilities to improve access and demand for care: To ensure the continuum of care for PPH prevention and management, referral systems need to be in place to ensure women can get to life-saving care when needed. Linking communities to nearby providers and facilities helps improve communication, care-seeking and referrals.

Mobilize CHWs and communities for PPH: Many countries have found CHWs invaluable in promoting birth preparedness and complication readiness?some expanding their role to deliver services and commodities, make referrals and monitor outcomes. They can also assist in mobilizing communities for birth preparedness/complication readiness (such as the successful Desa Siaga campaign in Indonesia) to arrange transport, funds and blood donors in emergencies.

Program Pitfalls and Lessons Learned: Behavior Change Communication

? Because communities often do not recognize maternal complications as a problem, conducting formative research helps to determine communities? understanding of the major killers of women and newborns, and enlisting leaders and influential people helps to develop solutions.

? Targeting behaviors, including key essential newborn care practices and care-seeking, can achieve significant improvements.

 

Resources: 

Misoprostol Information, Education and Communication: Examples from the Field

The following document is a guide to assist program planners on developing information, education, and communication (IEC) campaigns as part of a misoprostol program. The focus of the content and messaging is on misoprostol for the prevention and treatment of postpartum hemorrhage (PPH) in a developing country context. There are several print and media examples of VSI's IEC materials including pictoral directions for taking misoprostol, promotional posters highlighting a specific misoprostol product, health facility job aids, radio messages, and product packaging.

Key Counseling Messages for Pregnant Women (Annex D of the Program Implementation Guide for Advance Distribution of Misoprostol, 2013)

This document summarizes the key counseling messages for pregnant women and their support people for advance distribution of misoprostol programs.

Word file is attached for easy adaptation; see guidance on how best to use and adapt them in the full program implementation guide.

Clinical and Community Action to Address PPH

This 8-page document summarizes the Pathfinder International model based on 3 elements: advocacy; clinical interventions; and community engagement.

Community Education Fact Sheet for Preventing PPH

This 2-page fact sheet includes basic information for families and communities on preventing PPH including use of a skilled birth attendant, preparing for birth, recognizing heavy bleeding, and taking action.

Prevention and Treatment of PPH at the Community Level: A Guide for Policy Makers, Health Care Providers, Donors, Community Leaders and Program Managers

This document examines evidence related to the prevention and treatment of PPH, or one or more of its components, at the community level and when a skilled or nonskilled birth attendant is assisting the birth. The purpose of the document is to guide policy makers, health practitioners, donors, community leaders, and program managers who are developing community-based interventions to address the need to increase capacities at the household and community level to improve MNH and to respond to obstetric and MNH emergencies.

Prevention of Postpartum Hemorrhage: Learning

Resource Package for Community Health Workers

This training package was developed for training community health workers on PPH prevention at home births using misoprostol. Developed in Nepal,this 3-day course is designed to prepare female community health volunteers (FCHVs) to give information to pregnant women, their families, and their community members on the causes and prevention of excessive bleeding after childbirth. The course will focus on the use of Matri Suraksha Chakki (misoprostol) to prevent excessive bleeding after childbirth at home birth and will provide FCHVs with the attitudes, knowledge, and skills needed to provide Matri Suraksha Chakki to pregnant women in their communities.

Birth Planning Card

This 2-page form can be used in community programs to help women plan for births, including identifying a facility in case of complications and a blood donor.

Step 6: Monitor and Evaluate Results

Monitoring and evaluation of programs to prevent and treat postpartum hemorrhage is critical for measuring progress towards expected results and to generate sound data to inform decisions made by policymakers and program implementers at all levels of the health system.

Conduct nationally representative household and facility surveys that include PPH-related indicators: Periodic national and/or sub-national household and facility surveys can help to document current clinical practices, such as PPH screening, counseling and management, raise awareness, and generate support for PPH programming. Facility surveys that POPPHI conducted in eight countries and MCHIP conducted in six countries identified areas of strength and areas for improvement in service quality. ICF Macro?s Service Provision Assessment (SPA) and WHO?s Service Availability Mapping (SAM) facility surveys collect information on health care provider training and drugs, supplies and equipment to detect and manage severe bleeding in pregnancy.7 The SPA also includes direct observation of ANC visits and ANC client exit interviews. ICF Macro?s Demographic and Health Surveys (DHS), conducted every five years, and UNICEF?s Multi-Indicator Cluster Surveys (MICS), conducted in select countries every two years, collect population-based data on ANC services received by pregnant women, including counseling about danger signs in pregnancy, specifically bleeding in pregnancy, anemia testing and receipt of iron tablets.

Integrate PPH-related indicators into the national government health sector M&E plan:Depending on the range and scale of PPH interventions, the national M&E plan can be developed to: assess PPH program baseline; identify key indicators to measure progress

(outputs, outcomes and impact); and require review and strengthening of existing data collection systems. Revised global indicators to guide country health monitoring plans will be available in 2011 from a WHO-led maternal health indicators working group. An existing important resource that provides guidance on how to select and measure indicators related to antepartum and postpartum hemorrhage in the larger context of emergency obstetric care is WHO?s ?Monitoring Emergency Obstetric Care: A Handbook,? published in 2009. Routine PPH-related data collection should be integrated into existing government health management information systems (HMIS) to the extent possible. Additional M&E requirements beyond those addressed through the HMIS will need to rely on national surveys, as described earlier, and special studies and monitoring efforts.

Ensure the national HMIS adequately captures PPH data, and the information is used for decision-making: Existing HMIS forms and reports at the community, facility and district levels may not be sufficient to track PPH-related data at home births attended by a skilled birth attendant and antenatal and delivery care at facilities. If the data are captured in the patient charts or registers, they still many not be aggregated and reported up to district/provincial/regional levels. And in areas with high levels of unattended home births, CHW-delivered services (such as misoprostol distribution) may not be reported into the HMIS at all. These data together are needed to monitor uterotonic coverage across a district/province/region, track stockouts, and recognize improvements over time.

Document and disseminate results: Complementing the M&E plan, a knowledge management (documentation) plan needs to be developed to ensure the PPH program will capture sufficient information from prevention and management activities to answer all key programmatic questions. Because programs often begin as small-scale pilots, lessons learned and cost-effectiveness information are desired, but not routinely collected as part of the M&E plan. To ensure results are monitored, documented and disseminated, a documentation plan can help country teams plan to comprehensively capture program process and outputs. Furthermore, qualitative case studies and success stories of women, families, CHWs and facility-based providers help illustrate the effect of these life-saving interventions on program beneficiaries. This plan can also include journal article submissions about innovative program approaches that are of interest to a wider audience.

Program Pitfalls and Lessons Learned: M&E

? Inclusion of a national-level indicator for AMTSL?or, at a minimum, the use of a uterotonic in the third stage of labor?in the HMIS requires providers and district and regional officials to report on its use on a regular basis, thus making it more likely to be routinely practiced and recorded.

? The POPPHI Project demonstrated that the use of national survey data can serve as a powerful advocacy tool, as these data can provide a base from which to develop strategic action plans, create partnerships, link allies, implement needed activities, and monitor progress toward goals.

? Stakeholders should be informed and involved throughout program implementation, monitoring progress and reviewing findings, especially during pilot studies on innovative interventions or

approaches.

? Because the PPH prevention interventions are evidence-based, M&E can focus on program effectiveness in achieving coverage instead of measuring the reduction in mortality as a result. If there are sufficient resources, changes in mortality over time are powerful for advocating for scale-up.

 

Resources: 

Suggested Indicators for Monitoring and Evaluation of Programs to Detect and Treat Antepartum and Postpartum Hemorrhage

This compiled list includes output, outcome and impact indicators related to PPH prevention and management.

POPPHI Identifying Barriers to the Use of AMTSL by Providers: A Set of Tools

A set of simple qualitative research tools has been developed by POPPHI to help program planners better understand the attitudinal factors, barriers, and resistances to improved practice of AMTSL among both individual providers and obstetric teams. The tools also elicit information from a provider perspective on motivational factors and incentives to AMTSL use, and suggestions on how to effectively inform skilled attendants about the importance of AMTSL.

M&E ToolsResources: 

Recommended Core Indicators for PPH Prevention Program Monitoring and Evaluation (Annex F of the

Program Implementation Guide for Advance Distribution of Misoprostol, 2013)

The document summarizes the key indicators for advance distribution of misoprostol programs.

Word file is attached for easy adaptation; see guidance on how best to use and adapt them in the full program implementation guide.

Community Survey Tools

This is a collection of M&E tools for PPH programs. It includes:

1. Community Survey Tools Introduction2. Illustrative M&E Framework for CCA-PPH Projects: Key Indicators3. Facility Indicators for Clinical and Community Action for PPH Projects4. Survey Indicators5. Survey Respondents6. Household Survey7. Woman?s Questionnaire8. Questionnaire for Program Evaluation ? Instructions for Interviewers

Monitoring Emergency Obstetric Care: A Handbook

The purpose of this handbook is to describe the indicators and to give guidance on conducting studies to people working in the field. It includes a list of life-saving services, or ?signal functions?, that define a health facility with regard to its capacity to treat obstetric and newborn emergencies. The emphasis is on actual rather than theoretical functioning. On the basis of the performance of life-saving services in the past 3 months, facilities are categorized as ?basic? or ?comprehensive?. The section on signal functions also includes answers to frequently asked questions. The EmOC indicators described in this handbook can be used to measure progress in a programmatic continuum: from the availability of and access to EmOC to the use and quality of those services.

Active Management of the Third Stage Labor: Reporting Form

This form developed by POPPHI collects project and facility level data on AMTSL.

Community Postpartum Hemorrhage (PPH) Prevention Reporting Form

This form developed by POPPHI collects data related to AMTSL at the community level, especially at home births.

AMTSL Survey: Tools to Conduct a National Survey

The aim of the AMTSL national survey study is to advance our understanding of current AMTSL practices, to provide ministries of health (MOHs) and their international partners with the descriptive information necessary to assess AMTSL practices and to identify major barriers to its use. The POPPHI website contains a large number of resources for conducting a national AMTSL survey; selected resources are provided here. 

Country Program ResultsResources: 

Nigeria?s Clinical and Community Action to Address PPH: Technical Update

This 3-page program brief summarizes the Pathfinder project in Nigeria and includes lessons learned and recommendations, based ont he experiences implementing the Clinical and Community Action to Address PPH Model.

Misoprostol for Postpartum Hemorrhage, Reaching Women Wherever they Give Birth: Stories of Success in Bangladesh, Nepal, and Zambia

This publication presents stories from three countries- Bangledesh, Nepal, and Zambia- that offer inspiration and guidance for others seeking to expand access to misoprostol for PPH prevention and highlight the essential role of national level commitment and support for developing effective programs. Information for these stories came from a review of the literature and from interviews from key informants in each country.

Prevention of Postpartum Hemorrhage at Home Birth in Afghanistan

The purpose of this study was to demonstrate the safety, acceptability, feasibility, and program effectiveness (SAFE) of community-based distribution of misoprostol?an effective uterotonic drug?by Community Health Workers (CHWs) to reduce the incidence of PPH at home births in Afghanistan.The study included intervention group and comparison group. The study demonstrated that trained and supervised CHWs can successfully provide counseling and information on PPH prevention and can safely distribute misoprostol to women for use at a home birth. The study also demonstrates that the women and their support persons were able to understand and act on the messages given to them by the CHWs: there was not a single case of misuse of misoprostol.

Technical Brief #11: Community-Based Postpartum Hemorrhage Prevention in Nepal

Nepal Family Health Program (NFHP), the ACCESS Program with the Government of Nepal piloted a district-wide intervention to prevent PPH at home births through community-based distribution of misoprostol. This technical brief describes the intervention and findings.

Misoprostol Distribution during Antenatal Care Visits, Preliminary Report, Tanzania

This report presents preliminary results of the joint operations research project to assess the feasibility, program effectiveness, safety, and acceptability of misoprostol distribution via ANC visits to prevent PPH at home births.  Overall, these preliminary results are positive.  In terms of feasibility, ANC providers have been successful in recruiting women to the project during ANC visits, and we are seeing more women enroll in the project than expected.  In addition, of those who are eligible to receive misoprostol, virtually all women are given the drug during an ANC visit after they have reached 32 weeks gestation.  One challenge illuminated in these data is that women are returning to ANC after 32 weeks at a rate that is lower than expected

(54%). 

AMTSL Survey Reports

A number of countries conducted assessments of the major barriers to use of AMTSL and provide descriptive information necessary to assess AMTSL practices. These assessments can be powerful tools for advocacy and to direct resources to address identified gaps. See the annotated bibliography for multi-country AMTSL assessment analysis (Stanton et al).More information, tools and resources are available on the POPPHI website (www.pphprevention.org)

Pilot use of Oxytocin in a Uniject Device for AMTSL in Mali

This report describes use of the BD Uniject? device1 prefilled with 10 international units (IU) of oxytocin for actively managing the third stage of labor in selected health centers in Mali. Although this single-dose, autodisable injection device has previously been used for tetanus toxoid vaccination in Mali, the Ministry of Health lacked documentation of the safety and feasibility of using the device to deliver oxytocin for AMTSL.The study team used interviews and reporting forms to evaluate the use of the Uniject device with the TTI in several areas: coverage of AMTSL; feasibility, safety, and acceptability of the oxytocin-Uniject device with TTI in the Malian context; and experience with the TTI in the desert heat of Mali.

Prevention of Postpartum Hemorrhage Study, West Java, Indonesia

A study conducted by JHPIEGO?s Maternal and Neonatal Health (MNH) Program and its collaborators in Indonesia, with funding from USAID, offers evidence of the effectiveness of a community-based intervention to prevent postpartum hemorrhage (PPH). In the study, trained community volunteers provided women with information about prevention of PPH and the drug misoprostol (which controls bleeding following childbirth), distributed the medication to the women, and provided followup support. The community-based approach was found to be safe and acceptable to the women studied, contributing to their willingness and ability to use the drug appropriately.

Case Study: Somaliland. Prevention and Treatment of

PPH in Somaliland: Navigating a Complex Course to Greater Impact. PSI

This case study discusses how PSI/Somaliland is working to reduce the high maternal mortality rate through distribution of the uterotonic drug misoprostol for the prevention and treatment of post-partum haemorrhage, complemented by a targeted behavioral change communications (BCC) program promoting safe motherhood practices.

Step 7: Scaleup for National Impact and Sustainability

Scaling up capacity building, community outreach and demand generation for maternal and newborn health interventions is critical for sustaining program improvements. However, as country programs are selecting strategies and interventions to scale up AMTSL, they encounter large-scale challenges, such as inadequate providers? skills, low community awareness of danger signs and need for referral, and facilities without evidence-based protocols and medications.

Develop a scale up plan considering national priorities, areas of highest need and capacity: Depending on the national strategy, expansion of PPH initiatives may be phased but should be developed with a long-term vision of routine delivery of these services through existing government systems nationwide. Issues to consider and address in the plan include: logistics; product registration; training; funding; M&E (HMIS); behavior change communication; QOC; and capacity-building.

Plan for integration into other programs/services where feasible: Often PPH prevention and management interventions start as pilots, but once successfully demonstrated, scale up is challenged to shift from a vertical project to integrated activities within the broader maternal and newborn health national program. Integration makes sense when it?s synergistic?mutually strengthening and reducing needed resources (such as human, financial and time).

Consider the role of the private sector, including social marketing: PPH expansion should consider how to achieve the greatest coverage, which may include involving the private sector and social marketing/franchising.

Incorporate issues to promote sustainability: Sustainability can be built into the initial program design using the framework and tools. New innovations in particular need to consider sustainability in the initial design and implementation.

Program Pitfalls and Lessons Learned: Expansion & Sustainability

? When ownership of MNH services comes from the grassroots level, creating demand and supply, the health system and policy environment are more flexible to support decentralized implementation of the new interventions.

? A modern approach to training in basic EmONC competencies?with a greater focus on skill development?will increase provider confidence and capacity to adopt new practices.

? Maternal/newborn health interventions, and specifically BEmONC services, need more focused advocacy with key decision makers.

? In many countries with a human resources crisis, addressing improvements systematically is a challenge. Plans should be in place for community-based activities, including task sharing when appropriate, in order to ?decongest? maternity hospitals.

? Quality and performance improvement approaches, such as SBM-R, should focus an intensified effort on prevention and management of PPH as an essential element of quality care.

Resources: 

Nine Steps to Developing a Scaling-Up Strategy

This guide defines scale-up and presents a conceptual framework with nine steps to help bring a successful pilot project "to serve more people, more equitably and more lastingly".

En français, Neuf étapes pour élaborer une stratégie de passage à grande échelle

En español, Nueve pasos para formular una estrategia de ampliación a escala

Advance Distribution of Misoprostol Program Resources

This is a new section of the PPH toolkit developed in 2013 to complile existing resources related to Advance Distribution of Misoprostol for PPH Prevention Programs. The new Advance Distribution of Misoprostol for Self-Administration: Expanding Coverage for the Prevention of Postpartum Hemorrhage: Program Implementation Guide, developed by MCHIP is an essential starting point for program managers and technical advisors seeking to support expansion of PPH prevention programming.

This section has 7 sub-sections:

Implementation guide, plans, budget and job aidsProgram study briefs and case studiesClinical guidelines and protocolsAdvocacy materials and referencesTraining materials, job aids and supportive supervision toolsIEC materialsM&E tools

When appropriate, these resources also are linked within the 7 toolkit steps for easier overall access for PPH toolkit users.

A. Implementation guide, plans, budget and job aidsResources: 

Advance Distribution of Misoprostol for Self-Administration: Expanding Coverage for the Prevention of Postpartum Hemorrhage, Program Implementation Guide: Revised, November 2013

This new program guide was developed in 2013 to support expansion of programs focused on advance distribution of misoprostol for PPH prevention.It is designed to help program and technical staff from NGOs and INGOs develop programs in new areas in support of existing Ministry of Health safe motherhood programs, moving through three phases of program planning and implementation.

It is similar to the 2009 guide that supports introduction of misoprostol for PPH prevention, that also is available in this toolkit.

This is the revised version of this guide, November 2013 and contains all annexes in the main pdf file. Additionally, the annexes are posted as a separate file below in Word in case they need to be adapted.

Prevention of PPH at Home Births: Program

Implementation Guide

This guide is designed to help service providers and publich health decision-makers act now to being implementing programs that use community-based distribution of misoprostol as a tool in the fight against maternal mortality. Decades of research have proven the safety and efficacy of misoprostol. This guide will help service providers creat programs that reach the most vulnerable populations of women?those who live in rural areas and who are unable to access a skilled birth attendant to assist with delivery. It has been developed to provide the managers of RH programs with a step-by-step guide to setting up a community-based misoprostol program. It provides reality-based guidance for a country specific adaptation of misoprostol distribution.

Organizational Plans for Advance Distribution of Misoprostol

This spreadsheet includes up-to-date information on active or planned PPH programs. We welcome updates and additions to this spreadsheet. If your organization is implementing or planning to implement a PPH prevention program with advanced distribution of Misoprostol, please contact jessica.kerbo@jhpiego.org to update this information.

Forecasting Misoprostol Tablets for Postpartum Hemorrhage (PPH) Prevention and Treatment in Liberia

This Excel spreasheet file is a forecasting tool for misoprostol for PPH prevention and treatment. It is an example from Liberia, provided by VSI, but can be adapted for use in other country programs.

International Drug Price Indicator Guide

The International Drug Price Indicator Guide provides exactly what the name implies -- an indication of drug prices on the international market. The guide focuses on medicines on the WHO List of Essential Medicines, which includes misoprostol.

MSH, in collaboration with WHO, is working with partners to make existing drug price information more widely available in order to improve procurement of medicines of assured quality for the lowest possible price. This will contribute to equitable access to health services and commodities, including essential medicines, necessary for the prevention and treatment

of prevalent diseases

Nine Steps to Developing a Scaling-Up Strategy

This guide defines scale-up and presents a conceptual framework with nine steps to help bring a successful pilot project "to serve more people, more equitably and more lastingly".

En français, Neuf étapes pour élaborer une stratégie de passage à grande échelle

En español, Nueve pasos para formular una estrategia de ampliación a escala

Quantification of Health Commodities: A Guide to Forecasting and Supply Planning for Procurement

This guide for quantification of health commodities has been developed to assist technical advisors, program managers, warehouse managers, procurement officers, and service providers in (1) estimating the total commodity needs and costs for successful implementation of national health program strategies and goals, (2) identifying the funding needs and gaps for procurement of the required commodities, and (3) planning procurements and shipment delivery schedules to be able to ensure a sustained and effective supply of health commodities. The step-by-step approach to quantification presented in this guide is complemented by a set of product-specific companion pieces that provide detailed instructions for forecasting consumption of ARV drugs, HIV test kits, antimalarial drugs, and lab supplies.

This guide was developed by the USAID DELIVER Project, implemented by JSI.

B. Program study briefs and case studiesResources: 

Misoprostol for Postpartum Hemorrhage, Reaching Women Wherever they Give Birth: Stories of Success in Bangladesh, Nepal, and Zambia

This publication presents stories from three countries- Bangledesh, Nepal, and Zambia- that offer inspiration and guidance for others seeking to expand access to misoprostol for PPH prevention and highlight the essential role of national level commitment and support for developing effective programs. Information for these stories came from a review of the literature and from interviews from key informants in each country.

Availability Case Study: Misoprostol in Tanzania. VSI (2012)

In VSI's 2011 comprehensive assessment of current challenges to ensuring everyday availability of misoprostol in Tanzania, VSI describes the methodology to assess misoprostol availability as well as summarizes recommendations, key findings, and sample activities to make improvements and increase availability over time in Tanzania.

Prevention of Postpartum Hemorrhage at Home Birth in Afghanistan

The purpose of this study was to demonstrate the safety, acceptability, feasibility, and program effectiveness (SAFE) of community-based distribution of misoprostol?an effective uterotonic drug?by Community Health Workers (CHWs) to reduce the incidence of PPH at home births in Afghanistan.The study included intervention group and comparison group. The study demonstrated that trained and supervised CHWs can successfully provide counseling and information on PPH prevention and can safely distribute misoprostol to women for use at a home birth. The study also demonstrates that the women and their support persons were able to understand and act on the messages given to them by the CHWs: there was not a single case of misuse of misoprostol.

Technical Brief #11: Community-Based Postpartum Hemorrhage Prevention in Nepal

Nepal Family Health Program (NFHP), the ACCESS Program with the Government of Nepal piloted a district-wide intervention to prevent PPH at home births through community-based distribution of misoprostol. This technical brief describes the intervention and findings.

Prevention of Postpartum Hemorrhage Study, West Java,

Indonesia

A study conducted by JHPIEGO?s Maternal and Neonatal Health (MNH) Program and its collaborators in Indonesia, with funding from USAID, offers evidence of the effectiveness of a community-based intervention to prevent postpartum hemorrhage (PPH). In the study, trained community volunteers provided women with information about prevention of PPH and the drug misoprostol (which controls bleeding following childbirth), distributed the medication to the women, and provided followup support. The community-based approach was found to be safe and acceptable to the women studied, contributing to their willingness and ability to use the drug appropriately.

Case Study: Somaliland. Prevention and Treatment of PPH in Somaliland: Navigating a Complex Course to Greater Impact. PSI

This case study discusses how PSI/Somaliland is working to reduce the high maternal mortality rate through distribution of the uterotonic drug misoprostol for the prevention and treatment of post-partum haemorrhage, complemented by a targeted behavioral change communications (BCC) program promoting safe motherhood practices.

C. Clinical guidelines and protocolsResources: 

WHO Recommendations for the Prevention and Treatment of Postpartum Hemorrhage

These updated guidelines from WHO include 32 recommendations for PPH prevention and management, including the recommendation that "In settings where skilled birth attendants are not present and oxytocin is unavailable, the administration of misoprostol (600 ?g PO) by community health care workers and lay health workers is recommended for the prevention of PPH."

Note this document replaces several WHO guidelines previously posted in this toolkit:  WHO Recommendations for the Prevention of Postpartum Haemorrhage (2006); WHO guidelines for the management of postpartum hemorrhage and retained placenta (2009);

Prevention of Post-partum Haemorrhage with Misoprostol: FIGO Guideline, Annotated Version. International Federation of Gynecology and Obstetrics (2012)

This annoted version of the 2012 FIGO guidelins summarizes the background evidence regarding the use of misoprostol for the prevention of post-partum haemorrhage (PPH), discussing both misoprostol versus coventional injectible uterotonics and misoprostol in the prevention of PPH in situations where there is no  access to oxytocin. These guidelines also describe the recommended dosage, course of treatment, contraindications, and side effects, as well as discuss reports from ongoing programs in which women are given misoprostol tables for self-administration after delivery in settings where oxytocin is not available.

Treatment of Post-partum Haemorrhage with Misoprostol: FIGO Guideline, Annotated Version. International Federation of Gynecology and Obstetrics (2012)

This annotated version of the 2012 FIGO guidelines summarizes the background evidence regarding the use of misoprostol for the treatment of post-partum haemorrhage (PPH). These guidelines also describe the recommended dosage, course of treatment, the effect of repeat or consecutive doses, contraindications, precautions, effects and side effect. 

Country Example - Clinical Guidelines for the Prevention and Management of Postpartum Haemorrhage in South Sudan. MOH, Government of the Republic of South Sudan (2013)

These 2013 official clinical guidelines describe key PPH prevention interventions- for both facility and community based births. They also outline the general management of PPH,

including uterotonics that can be used, and the diagnosis and management of PPH after childbirth according to specific causes.    

Managing Complications in Pregnancy and Childbirth?A Guide for Midwives and Doctors

As part of the WHO Integrated Management of Pregnancy and Childbirth series, the MCPC is a reference manual intended for use by midwives and doctors at the district hospital iwho are responsible for the care of women with complications of pregnancy, childbirth or the immediate postpartum period, including immediate problems of the newborn. While most pregnancies and births are uneventful, all pregnancies are at risk. Around 15% of all pregnant women develop a potentially life-threatening complication that calls for skilled care and some will require a major obstetrical intervention to survive. The interventions described in these manuals are based on the latest available scientific evidence.  It is hoped that this manual will be used at the side of the patient, and be readily available whenever a midwife or doctor is confronted with an obstetric emergency.In addition to the care midwives and doctors provide women in facilities.

D. Advocacy materials and referencesResources: 

Advocacy, Approval, Access: Misoprostol for Postpartum Hemorrhage; A Guide for Advocacy

This publication provides guidance to national advocates and civil society organizations in conducting effective advocacy for the successful uptake of misoprostol for PPH.  Available in English and French.

Global Misoprostol Registration by Indication (map & detailed spreadsheet). VSI. May 2013

VSI prepared this useful map to show the status of regulatory approvals of misoprostol globally.  This map highlights the various types of indications misoprostol is approved for, such as PPH, other obstetic indications, gastric ulcers, etc.

Smith et al. Misoprostol for postpartum hemorrhage prevention at home birth: an integrative review of global implementation experience to date. BMC Pregnancy and Childbirth 2013. 13:44

This article is an integrative review of published research studies and evaluation reports from 18 programs that distributed misoprostol at the community level for PPH prevention at homebirths.  Based on the results of this review, the authors concluded that community-based programs for the prevention of PPH at homebirth using misoprostol can achieve high distribution and use of the medication, using diverse program strategies. Coverage was greatest when misoprostol was distributed by community health agents at home visits. Programs appear to be safe, with an extremely low rate of ante or intrapartum administration of the medication. 

Misoprostol for Maternal Health

The Caucus on New and Underused Reproductive Health Technologies is a community of practice established under the auspices of the Reproductive Health Supplies Coalition, for which PATH serves as Secretariat. Caucus members developed this series of peer-reviewed briefs on underused reproductive health technologies. This brief details efficacy, current program use, manufacturers and suppliers, registration status, and public-sector price agreements for misoprostol.

Policy Brief: Scaling up Misoprostol for Postpartum Hemorrhage: Moving from Evidence to Action. FCI (2012) (English and French)

This useful policy brief explores strategies to help governments and their partners reduce maternal mortality by expanding access to misoprostol for PPH. Importantly, this briefer highlights key elements for introducing misoprostol for PPH, including creating a supportive national policy; including misoprostol in national health budgets; preparing and disseminating national clinical guidelines; training health workers; ensuring consistent supply and

distribution; and building community awareness and demand.

Preventing Postpartum Hemorrhage at the Community Level: A compendium of operations research

This compendium summarizes the results from a series of VSI-led independent operations research programs across seven programs in Africa and Asia between 2008 and 2012.  The goal of these programs was to determine the feasability, acceptability, and program effectiveness of misoprostol use to prevent PPH at the community level. This report summarizes the country findings from Bangladesh, Ghana, Nigeria, Tanzania, Kenya, Zambia, Mozambique, as well as identifies several facilitating factors that contributed to program success that can increase the likelihood of scale-up on a national level. These factors include strong government support; high levels of antenatal care coverage; the identification of local methods to measure blood loss; and the adaptability of program methods to the local context.

Durocher J et al 2010. High fever following postpartum administration of sublingual misoprostol. BJOG 17(7): 845-852

This paper evaluates factors leading to an elevated body temperature in some women given misoprostol for treatment of postpartum haemorrhage. 

Tang et al. Misoprostol: Pharmacokinetic profiles, effects on the uterus and side-effects. Int J Gynaecol Obstet. 2007. 99: S160-S167.

This article summarizes studies of misoprostol's pharmacokinetics and effects on uterine activity that have demonstrated properties of the drug after various routes of administration, whether orally, vaginally, sublingually, bucally or rectally. These studies can help to discover the optimals dose and route of administration of misoprostol for individual clinical applications, including the management of PPH. For example, it was found that the increase in uterine tonus is more rapid and more pronounced following oral and sublingual treatment than after vaginal treatment. A discussion of side effects reveals that Misoprostol is a safe drug but serious complications and teratogenicity can occur with unsupervised use.

Hemmerling A. 2006. The safety of misoprostol. In't JGO

http://bixby.berkeley.edu/wp-content/uploads/2010/05/The-safety-of-misoprostol-11.06.pdf

Misoprostol for Prevention of Postpartum Hemorrhage: An Evidence-based Review by the United States Pharmacopeia

This publication discusses the evidence regarding the use of misoprostol for the prevention of postpartum hemorrhage and based on their review of studies, the consensus of the U.S. Pharmacopeia Expert Advisory Panel is that the prevention of PPH should be considered as an accepted indication in the USP Drug Information (DI) monograph on misoprostol. They recommended misoprostol as an alternative agent in reducing the incidence of PPH , especially in situations in which oxytocin and other uterotonic drugs are not available, such as in developing countries.

misoprostol.org

This site is dedicated to providing information on the use of misoprostol in obstetrics and gynecology.  It links to many additional resources and includes an extensive bibliography of over 1500 misoprostol references: http://www.misoprostol.org

Oladapo OT. Misoprostol for preventing and treating postpartum hemorrhage in the community: a closer look at the evidence. Int J Gynaecol Obstet. 2012;119:105-110.

Can't find this doc in the folder; would this just the link to the journal or do I still need to provide a summary?

E. Training materials, job aids and supportive supervision toolsResources: 

South Sudan Trainer Handbook - Training of Health Facility Staff: Clean and Safe Delivery and Management of Postpartum Haemorrhage (2013)

This training manual is designed to prepare the skilled health care workers in a 5 day training- who are based at health facilities and are primarily responsible for providing ANC, labour and delivery, and care after childbirth to women and their newborns- to prevent PPH and manage PPH at the facilities and thereby reduce maternal deaths in South Sudan. Specifically, the course will prepare the health facility staff to:? Counsel women attending ANC clinic on making birth preparedness and complication readiness (BP/CR) plans and preventing PPH using misoprostol during home births.? Provide safe and clean birth including prevention and management PPH cases at the health facility and refer cases to higher level as appropriate.This trainers handbook includes trainer instructions, course content and outlines, learning activities including case studies and role plays and answer guides, pre and mid course knowledge assessment questionnaires and answer keys, and detailed information for conducting the course.

South Sudan Trainers Handbook - Training of Home Health Promoters: Prevention of Postpartum haemorrhage at the community Level (2013)

This training manual was developed for training community Home Health Promoters (HHP) on the expansion of PPH prevention programs using misoprostol at home births. Adapted from the Afghanistan Trainer's Handbook for the Training of CHWs, the goal of this 4-day course is to provide participants with the knowledge, skills and attitudes needed to counsel pregnant women, their support persons, families and other community members about the importance of taking misoprostol tablets for the prevention of PPH and what actions to perform when PPH occurs. 

Sample training schedules for providers and CHWs (Annex B and C of the Program Implementation Guide for Advance Distribution of Misoprostol, 2013)

Annex B contains the 5-day course syllabus and schedule for training facility-based providers on PPH prevention and management in the context of a advance distribution of misoprostol program area. Annex C is a 4-day course syllabus and schedule for CHWs/TBAs on PPH

prevention for advance distribution of misoprostol programs.

Word file is attached for easy adaptation; see both annexes and guidance on how best to use and adapt them in the full program implementation guide.

CHW supervision checklist (Annex E of the Program Implementation Guide for Advance Distribution of Misoprostol, 2013)

This CHW supervision checklist helps provide supportive supervision for CHWs in advance distribution of misoprostol programs.

Word file is attached for easy adaptation; see the annex and guidance on how best to use this tool in the full program implementation guide.

Madagascar Trainer Handbook ? Curriculum de Formation des Agents de Sante: Prevention des Hemorragies du Postpartum. (French only)

This trainer's handbook is designed to prepare the skilled health care workers who are based at health facilities and are primarily responsible for providing ANC, labour and delivery, and care after childbirth to women and their newborns, to prevent PPH and manage PPH at the facilities and thereby reduce maternal deaths in Madagascar. Specifically, the 3-day course will reinforce the AMTSL skills of health facility staff to prevent PPH as well as prepare the health facility staff to counsel women attending ANC clinic on making birth preparedness and complication readiness (BP/CR) plans and preventing PPH using misoprostol during home births.

Madagascar Participant Handbook ? Formation des Agents de Sante: Prevention des Hemorragies du Postpartum

This participants handbook is designed to prepare the skilled health care workers who are based at health facilities and are primarily responsible for providing ANC, labour and delivery, and care after childbirth to women and their newborns, to prevent PPH and manage PPH at the facilities and thereby reduce maternal deaths in Madagascar. Specifically, the 3-day

course will reinforce the AMTSL skills of health facility staff to prevent PPH as well as prepare the health facility staff to counsel women attending ANC clinic on making birth preparedness and complication readiness (BP/CR) plans and preventing PPH using misoprostol during home births.

Prevention of Postpartum Hemorrhage: Learning Resource Package for Community Health Workers

This training package was developed for training community health workers on PPH prevention at home births using misoprostol. Developed in Nepal,this 3-day course is designed to prepare female community health volunteers (FCHVs) to give information to pregnant women, their families, and their community members on the causes and prevention of excessive bleeding after childbirth. The course will focus on the use of Matri Suraksha Chakki (misoprostol) to prevent excessive bleeding after childbirth at home birth and will provide FCHVs with the attitudes, knowledge, and skills needed to provide Matri Suraksha Chakki to pregnant women in their communities.

South Sudan Participant Handbook - Training of Health Facility Staff: Clean and Safe Delivery and Management of Postpartum Haemorrhage (2013)

This training manual is designed to prepare the skilled health care workers who are based at health facilities and are primarily responsible for providing ANC, labour and delivery, and care after childbirth to women and their newborns, to prevent PPH and manage PPH at the facilities and thereby reduce maternal deaths in South Sudan. Specifically, the 5-day course will prepare the health facility staff to:? Counsel women attending ANC clinic on making birth preparedness and complication readiness (BP/CR) plans and preventing PPH using misoprostol during home births.? Provide safe and clean birth including prevention and management PPH cases at the health facility and refer cases to higher level as appropriate.This Participants? Handbook details the practices and knowledge with learning activities (trainers must also have and read a copy of this as it contains many of the materials to be used). This serves as the ?text? for the participants and the ?reference source? for the trainer however additional resources can be used. In addition, because the manual and additional reference materials only contain information that is consistent with the course goals and objectives, they become an integral part of all classroom activities, such as giving an interactive lecture or leading a discussion.

South Sudan AMTSL jobaid

This useful job aid describes-with both instructions and illustrations- how to carry out the Active Management of the Third Stage of Labor (AMTSL).

Afghan Trainers Manual ? Training of CHWs: Expansion of Prevention of Postpartum Haemorrhage Program in Afghanistan

Afghan Trainers Manual ? Training of CHWs: Expansion of Prevention of Postpartum Haemorrhage Program in Afghanistan

Coaching Skills Checklist

Checklist for coaching skills for trainers or observers.

F. IEC materialsResources: 

Misoprostol Information, Education and Communication: Examples from the Field

The following document is a guide to assist program planners on developing information, education, and communication (IEC) campaigns as part of a misoprostol program. The focus of the content and messaging is on misoprostol for the prevention and treatment of postpartum hemorrhage (PPH) in a developing country context. There are several print and media examples of VSI's IEC materials including pictoral directions for taking misoprostol, promotional posters highlighting a specific misoprostol product, health facility job aids, radio messages, and product packaging.

Key Counseling Messages for Pregnant Women (Annex D of the Program Implementation Guide for Advance

Distribution of Misoprostol, 2013)

This document summarizes the key counseling messages for pregnant women and their support people for advance distribution of misoprostol programs.

Word file is attached for easy adaptation; see guidance on how best to use and adapt them in the full program implementation guide.

External Packaging: Rwanda (local language)

This external packaging for misoprostol is designed for use in Rwanda and is in the local language, Kinyarwanda.  It is in a wedge or compressed pack to make it more compact.

Packaging inserts/instructions for use: Madagascar, Zambia, Liberia, South Sudan

These package inserts from several countries, including Madagascar, Zambia, Liberia and South Sudan, are designed to put into external misoprostol packages.  They contain illustrations and text about how to properly use misoprostol, as well as warnings about drug misuse and potential side effects. 

Flipchart: Birth Preparedness and Complication Readiness (text included on the CHW side), Afghanistan

One flipchart developed for use in Afghanistan portrays several different scenes- with corresponding text- related to Birth Preparedness and Complication Readiness, including  a Community health worker visiting a family and motivating pregnant woman for seeking antenatal care; antenatal care visits; dielt during pregnancy; rest and pregnancy; saving money for emergency readiness; measuring pregnant woman blood group and identifying a blood donor; arranging emergency transport; danger signs; presense of a skilled birth attendant at the time of delivery; and feedback from the pregnant woman. 

Flipchart: PPH (Text included on the CHW side), Afghanistan

One flipchart developed for use in Afghanistan portrays several different scenes- with corresponding text- related to the prevention of PPH, including the importance of SBA during delivery; when misoprostol tablets should be taken; the dangers of taking the tablets during pregnancy before the delivery of the baby; signs of heavy bleeding after the birth of the baby, etc. 

Flipcards: PPH (illustrations only, designed for illiterate CHWs), South Sudan

One flipchart developed for use in South Sudan portrays several different scenes- with corresponding text- related to the prevention of PPH. These materials are desgined for illiterate CHWs, so there are only illustrations (no text).

Flipcards: Birth Preparedness and Complication Readiness (illustrations only, designed for illiterate CHWs), South Sudan

One flipchart developed for use in South Sudan portrays several different scenes- with corresponding text- related to Birth Preparedness and Complication Readiness. These materials are desgined for illiterate CHWs, so there are only illustrations (no text).

G. M&E toolsResources: 

Recommended Core Indicators for PPH Prevention Program Monitoring and Evaluation (Annex F of the Program Implementation Guide for Advance Distribution of Misoprostol, 2013)

The document summarizes the key indicators for advance distribution of misoprostol programs.

Word file is attached for easy adaptation; see guidance on how best to use and adapt them in the full program implementation guide.

Database report sample

This Dashboard report, which is generated by the MCHIP central database of Comprehensive PPH Programs, provides a snapshot of key information, such as program information, number of deliveries, months of stock-outs, women counselled and provided misoprostol, uterotonic coverage, and uterotonic coverage by place of birth (home birth and facility).  

CHW register pictorial form: South Sudan (Annex G of the Advance Distribution of Misoprostol for Self-Administration Program Implementation Guide)

Using colorful images (for illiterate CHW), this form depicts in checklist format what the CHW should discuss with the woman (if participating in a comprehensive PPH program) and her family during anetenal care and postnatal care visits.

Provider/CHW Survey

This survey for both skilled providers and CHW is to be used with all trained in the distribution of misoprostol. This questionnaire assesses health provider?s and CHWs knowledge on BPCR and misoprostol Health providers and CHWs.

AMTSL Observation Checklist

This checklist is to be used during supervisory visits to assess provision of AMTSL by standard.

Monthly Misoprostol and Oxytocin Consumption

logbooks: Facility-based distribution monthly stock report

These logs are to be used at each health facility to record misoprostol & Oxytocin stock and distribution.

Misoprostol Postpartum Questionnaire: English & French

This questionnaire captures key information related to knowledge about misoprostol, delivery, self-administration of misoprostol, birth outcome, and complications.

Hospital admission form/Adverse event reporting form

This form is to be completed upon the event of an adverse medical event  (serious event or complication) following administration of Misoprostol. It asks details about background information, the type of adverse event, type of complication, and drug administration information.

Maternal Death Audit form

This form- developed for use in South Sudan- is to be completed upon the death of a women following administration of Misoprostol. It asks details about the woman's background, maternal obstetric history, history of current pregnancy, intrapartum and postpartum information, and the cause of death the type of adverse event, type of complication, and drug administration information.

Data Collection Tools for Comprehensive PPH programs

These data collection tools were developed for use in the Madagascar comprehensive PPH prevention program.

Monitoring and Supervision tool for facility-based distribution of misoprostol

This tool helps monitor misoprostol supplies and distribution at health facilities, ensuring the misoprostol is properly stocked, stored, and accounted for by health facility staff.

Field Manuals and data collection plans outlining M&E procedures and responsibilities

These program implementation documents include manuals and data collection plans outline M&E procedures and responsibilities for staff who are carrying out comprehensive PPH programs.

References

1World Health Organization. Mother-baby package: Implementing safe motherhood in countries. 1998;WHO/FHE/MSM/94.11.

2WHO defines an SBA as ?an accredited health professional?such as a midwife, doctor or nurse?who has been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth, and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns.?

3WHO and UNICEF. Countdown to 2015 Decade Report (2000?2010).

4 Ifakara health Institute. Misoprostol Distribution during Antenatal Care Visits; Preliminary Report. December 2009.

5Pagel C et al. Estimation of potential effects of improved community-based drug provision, to augment health-facility strengthening, on maternal mortality due to post-partum haemorrhage and sepsis in sub-Saharan Africa: an equity-effectiveness model. The Lancet. 2009.

6Sanghvi H et al. Prevention of postpartum hemorrhage at home birth in Afghanistan. IJOG. 2009.

7WHO is also currently working on a new set of survey tools, the Service Availability and Readiness Assessment (SARA).

Source URL: https://www.k4health.org/toolkits/postpartumhemorrhage